I take a deep breath as I get ready to go see Mrs. H. I can predict after sign-out from the ER doc where this is likely to go. Mrs. H. is an 87 year-old woman who comes to the emergency room with weakness. She stumbled and fell to the floor but could not get up to reach the phone to call for help. She laid there on the floor for an hour until her son stopped by to visit and brought her to the ER. Through diligent testing, she is found to have a urinary tract infection and dehydration. She has a few bruises, but nothing is broken. Her son is with her in the emergency department, and he is relieved that she will be admitted to the hospital (admitted – as far as he is concerned). He has been afraid something like this would happen to her for a long time. Mrs. H. has been widowed for eight years. Her son checks on her every other day, and this is her third fall in the past six months. He is hoping that she can come in to the hospital and go somewhere she can get more assistance.
Overnight, she is feeling a little better, thanks to the antibiotics and IV fluids. The next morning, she is evaluated by our physical and occupational therapists, who determine that she needs 24 hour supervision and assistance with activities of daily living (ADL’s).
And now…time for the dance. Mrs. H. is frail, on the margins of living independently. She is in need of at least a rehab stay to see if she can gain some strength, or more likely a move to a higher level of assistance. As physicians, we all know that there is nothing in Medicare’s eyes that make Mrs. H. warrant inpatient admission. If she is lucky (?!?) she has actually become more ill overnight. Could she be just a little sicker? You know, not so sick that she gets in trouble, but just a little more sick. Maybe now she has some mild renal failure. Or perhaps she is a little hypoxic. Or maybe her WBC count has risen enough that now she has features of sepsis or SIRS. All these are little things that tip the balance from an “Obs” stay to an “inpatient” stay. Does anyone else feel a little dirty cheering for a more complex diagnosis that warrants inpatient status so our frail elderly patient may actually cross that three-night threshold so Medicare will pay for TCU stay?
As physicians, we are told that it is our decision whether to admit frail patients or condemn them to “observation.” While it is true that we have the power of the pen (or keyboard, as the case may be), I have to admit I feel fairly impotent in cases like this. Even the “two midnight rule” meant to address some of the issues with inpatient vs. observation designation does not really help us decide what to do with that subset of patients who are not so ill they need inpatient medical care, but they are too frail to live alone and need twenty-four hour care. Hospitals are up against RAC contractors who have up to three years to review and challenge an inpatient/obs order and get to keep a percentage of any recovered money. Our hospital has an entire utilization review department to fish through labs and diagnoses to try to find something that sticks for inpatient status. Other hospitals farm this duty out to outside businesses that do this process for them. And we wonder about waste in the healthcare setting.
At the same time, our patients are becoming more savvy about asking about whether they are admitted or whether they are under observation. AARP has done stories about this issue, lawsuits have been filed against Medicare, and self-help packets exist for patients to fight observation status. In many ways, these are good things, yet they drive a wedge between us and our patients. At the very least, it can lead to a lack of trust on the part of our patients. And they still do not address the crux of the problem – that we have many frail elders who are one slight illness away from losing independence. Medicare and our hospital system is not equipped to do right by these patients.
I dread the conversations with family when Mrs. H. is deemed “medically stable for discharge.” Yes, it is true that she could be cared for in a less intense setting if she had 24-hour supervision. She does not really need more IV fluids, more antibiotics, or more medical treatment persay, yet she can no longer live at home alone. Mrs. H’s family has been working admirably to guard her independence, but they have the caregiver fatigue that can come from caring for a frail elder. They have been trying to honor her wish to be at home, yet they are not willing to move her into their home (and she does not want to move). Many patients in her shoes have lived frugally and have saved a small nest-egg. Enough to live on for now, but not enough to pay for TCU, nursing home, or assisted living care for more than a few months.
A loss of independence can be a terrible emotional blow for many of our patients. I cannot imagine facing such a life change and being expected to adjust to it in one, or even three nights in the hospital. Add the financial burden and strain, and the issue becomes more and more complex.
I see similar scenarios to Mrs. H. play out every week I am on service. How are we to honor and care for our elders? As more baby boomers age, this challenge will be more and more pressing. At the very least, I would like to see observation in the hospital count towards medical need for transitional care. We will need a multi-pronged approach that includes hospital systems continuing to care for the ill, affordable transitional and long-term care, and families picking up slack and caring for their aging loved ones.
But until there is some sort of fix, I will continue to be a little relieved when my frail elderly patients get a little sicker…and continue to feel frustrated.
Dr. Brett Hendel-Paterson wears several varied professional hats. He is board-certified in internal medicine, pediatrics, and palliative care. He is a med/peds and palliative care hospitalist at HealthPartners Regions Hospital in St. Paul, MN. He also has tropical medicine training with a CTropMed® from the American Society of Tropical Medicine and Hygiene (www.astmh.org), where he is a counselor with the clinical group. He is an assistant professor of internal medicine and global health at the University of Minnesota (www.globalhealth.umn.edu), and he is a codirector of the University of Minnesota Global Health Course.
His professional passions and interests span medical education, palliative care, health disparities, internal medicine, tropical/travel medicine, and immigrant/refugee health. When he is not attending he is active working with the global health track in the University of Minnesota internal medicine residency.
He received his undergraduate degree from Grinnell College, attending the University of Minnesota-Duluth for medical school, and the University of Minnesota for his med/peds residency.
Outside work, he spends his time chasing down his two sons in elementary school, enjoying the outdoors, exercising, cooking, and music. His recent diagnosis of Chronic Lymphocytic Leukemia in the summer of 2013 has required some significant work/life rebalancing and has underscored the importance of caring for patients in an empathic and kind manner in times when many are feeling particularly vulnerable.